FAQ Category: Lumbar Spine

Cauda equina refers to the bundle of spinal nerves at the bottom of the spinal cord. The term actually means tail of the horse. The many nerves bunched together at the base of the spine resembles a horse’s tail.

Pressure on the nerves in this area can cause a group of symptoms referred to as cauda equina syndrome (CES). Symptoms vary from patient to patient. These include low back pain, sciatica (pain and/or numbness down the leg), and numbness in the groin area.

Other symptoms commonly reported with CES can include leg weakness, and loss of bowel and/or bladder control. Men may have difficulty getting an erection or keeping an erection. This additional problem is called erectile dysfunction. Women may have increased pain during sexual intercourse or difficulty having an orgasm. Very few people have all of the symptoms.

Anything that can put pressure on the cauda equina can cause CES. The most common causes are disc herniation and spinal stenosis. Stenosis is a narrowing of the opening in the bone for the nerves to pass through.

Surgery is important to prevent permanent damage and loss of function. Even with surgery, many people are left with some problems, most often urinary incontinence (leaking or dribbling urine).

There isn’t a clear answer to your question. Recovery can take months to years if there’s been a change in sensation or loss of motor function from nerve damage. In some cases, complete recovery doesn’t happen.

Pressure on the lower spinal nerves called the cauda equina can cause a wide range of symptoms referred to as cauda equina syndrome (CES). There can be back and leg pain, numbness in the legs, bowel and bladder problems and sexual dysfunction.

Studies show that continued recovery from these problems has been observed after surgery for CES. Gradual improvement for up to three to four years after the operation has been reported. Decompressive surgery is done to take pressure off the cauda equina. In the case of a herniated disc, this can be done by removing the disc, a procedure called discectomy.

According to a recent review of CES, one-third did not get back to normal. Urinary incontinence (leaking or dribbling urine) was the most common problem before and after surgery. Other problems with bladder control included difficulty starting a flow of urine and urine retention.

Studies show that nearly 80 per cent of the U.S. (adult) population will have at least one episode of low back pain (LBP) in their lifetime. At least half of those people will have more than one flare-up or relapse.

Recognizing a new problem isn’t always so easy. Sometimes the symptoms are different enough to send a person back to the doctor for a re-check. In other cases, the amount of time that has passed between episodes is enough to suggest a separate problem.

Recurrent LBP within a short period of time is often blamed on the original problem. These flare-ups can occur anywhere from two days to two months after the initial episode.

Flare-ups are often defined as an increase in pain intensity. If pain is rated on a scale from zero (no pain) to 10 (worst pain), then a two-point increase over usual pain is a flare-up.

If your symptoms are not gradually getting better and you notice over time more flare-ups lasting longer, then a medical recheck is probably a good idea. If you have a clean bill of health then it may be just a matter of managing your back pain.

Estimates are high that U.S. workers will get back pain sometime in their lives. Some, but not all, are work-related. Relapses and flare-ups are common. The amount of work productivity lost can be measured in the billions. Disability and poor quality of life are long-term problems for some people.

Who’s at risk and how to avoid this problem is the focus of many studies. There’s plenty of evidence that emotional or psychologic stress are major factors. People who aren’t happy on the job are also at increased risk.

Prevention for you may be as simple as watching your posture and body mechanics. Bend at the knees, not at the waist. Move your feet to get where you need to be. Don’t overreach. Pace yourself and remember to breathe deeply and regularly — especially if you have a tendency to hold your breath while working.

If you have to do any heavy lifting, get help. Plan the lift and count to three so that you lift at the same time. Whenever lifting, try to hold the object as close to your body as possible. Holding heavy objects out and away from the body increases the load through your arms to your spine.

Experts have not found a quick cure or one-size-fits-all treatment approach to back pain. It’s clear that inactivity is not helpful. If you hurt your back, rest for a day or two, but don’t stay down long. Motion is lotion and gentle movement is best — even in the early, acute stages.

Chances are that if you like your job or you are motivated to work, a little prevention goes a long way. Your chances of back injury decrease with a positive attitude and proper prevention.

Low back pain (LBP) in the work place is costing American businesses billions of dollars in lost productivity. Many studies have been done to figure out the how, why, and who of back pain.

We know that on any given day about 15 per cent of the work force has LBP. Some come to work while others stay home. Caucasian (white) blue-collar workers are the most likely to report episodes of LBP. Workers without a high school diploma are three times more likely to have LBP compared to workers with a diploma or college degree.

Psychologic factors such as job satisfaction has been shown to be linked with LBP. The cost of absenteeism due to back pain combined with lost production time for those who do come to work with LBP is estimated at $7.4 billion/year.

How much of that cost is directly caused by job dissatisfaction is unknown. Scientists are studying ways to predict which workers will have back pain based on a wide range of factors known to be related to LBP.

Results of long-term are very encouraging. After five to 10 years, most patients with sciatica from a disc problem are back to work. Sometimes a job switch is necessary, but not always.

Conservative (nonoperative) care with medications to relieve pain and reduce inflammation can be successful. Exercise is another important tool in recovery from discogenic back pain. Physical therapy may be needed. If conservative care fails to help, then surgery to remove the disc may be advised.

Discectomy is the name of the operation. In many cases, this surgery can be done as an out-patient with minimally invasive techniques. The surgeon may only make an opening small enough to insert a long thin needle called an endoscope.

A tiny TV camera on the end allows the surgeon to see inside your spine and carefully remove any disc fragments. No further treatment may be needed.

Only a small number of people with disc problems or other back pain end up with long-term disability. Talk to your doctor about your situation. Find out what your options are and focus on health and healing.

Studies all over the world report back pain in adults. The incidence ranges from 10 to 80 per cent. Most experts agree that the 80 per cent is more accurate.

What happens over time is called the natural course of a disease, illness, or condition such as low back pain (LBP). Most researchers follow back pain patients up to two years. A few report results after five years. Only a small number are on record reporting 10-year outcomes.

Recently, a group of researchers from Sweden studied 790 adults seeing help from a doctor for their first episode of LBP. They followed this group for five years to study the natural course of the condition and to see what effect general exercise had on LBP. Results were compared for men and women.

What they found was that results don’t differ much between the sexes. In other words, the natural course of LBP was very similar for men and women. Pain intensity and disability improved most during the first six months after the start of the LBP.

Loss of function and disability were the most common reasons why people went to a doctor. Repeated episodes of back pain were reported in up to two-thirds of all patients. General exercise doesn’t seem to speed up recovery. Other studies report that specific back exercises can make a difference.

Exercise of any type has value. It increases blood flow and circulation. Exercise is also known to increase natural pain killer cells called endorphins. Endorphins are natural mood elevators, too so exercise can decrease depression and improve your outlook.

A recent study from Sweden reported that regular or general exercise doesn’t seem to make a difference in how fast people recover from back pain. However, pain intensity is lower for people who exercise regularly at higher levels of intensity.

Most of the nearly 800 people in the study reported that improvements in pain and function were greatest in the first six months after back pain started. If you find that your pain is not going away, see your doctor again.

If there are no serious problems found, then a more specific program of back exercises may be needed. You can see a physical therapist for this type of program. Many health clubs have a physical therapy department on site to help their clients with problems of this type.

Many people who have had accidents or injuries with long-lasting symptoms face this dilemma. If painful symptoms persist past the time for expected physiologic healing, then your pain becomes chronic instead of acute. Most soft tissue and bone injuries take six to 12 weeks to heal.

Pain from injury, stretch, or trauma to any of the nerve tissues is called neuropathic. This type of pain can last much longer. If the nerve is able to heal or regenerate, then your symptoms may improve over a period of 12 to 18 months. Once again, pain after that time period becomes chronic.

When the doctor told you the pain isn’t a sign of harm, he or she was referring to the fact that in cases of chronic pain, the pain is not a signal that you are injuring or re-injuring yourself. It’s likely that you will have the pain no matter what you do.

In other words, whether you sit in a chair or remain active, you’ll have the same painful response. If that’s the case, then patients are encouraged to remain as active as possible. The situation becomes one of pain control or management rather than cure.

You may be referring to a functional restorative program designed to increase your function and activity within the confines of your painful symptoms. In other words, you will be restored to a higher level of function but not necessarily cured of your pain.

Programs of this type started up after research clearly showed that many chronic back pain patients are afraid to move. They avoid any motions that might cause pain and believe that pain is a sign of bodily harm or damage. This behavior is called fear avoidance behavior (FAB).

We now know that activity avoidance will not help and may make you worse. A program of functional restoration can help you learn how to recognize when you are avoiding activities and shouldn’t. A physical therapist and behavioral psychologist usually work together to help patients move past these limitations.

Most programs of this type teach chronic pain patients about FAB and then help you to slowly change your habits. A graded (slowly progressive at your own pace) program of exercise is included. Group therapy with other patients helps you learn how to change the way you think about your pain and movement.

Most patients find they have improved mood (less depression and anxiety) and improved quality of life after a functional restorative program. Studies show less disability and improved function after only six to eight weeks.

The risk of serious low back pain (LBP) doesn’t go up with the diagnosis of lumbar spine disc degeneration. In other words, you are no more likely to injure yourself than someone with a perfectly normal spine.

A recent long-term study over five years done at Stanford University (California) verified these findings. Despite the common sense idea that people with degenerative disc disease are more likely to suffer serious harm from minor trauma, it just isn’t true.

In fact, the study confirmed what many other studies have been reporting all along. And that is — behavioral and psychologic factors are far better predictors of LBP than anything else. This refers to factors such as psychologic distress, smoking, and ongoing worker’s compensation issues.

Back injuries can be reduced and even prevented with proper lifting techniques. Most back injuries involving lifting loads are linked with lifting in an awkward position or lifting loads too heavy for the person’s size and strength.

A positive attitude and proper lifting will go a long way in preventing serious low back illness — even in someone with known degenerative disc disease.

You ask a very good question and one that many scientists are studying daily. It’s true that most low back problems occur out of the blue during daily activities. They aren’t the result of a sports injury or trauma of any kind.

One thing research has shown: people with other chronic pain problems (nonspinal) are more likely to develop back pain than healthy adults. About 60 to 70 per cent of chronic back pain patients fall into this category. Individuals with mental health disorders, including depression are at increased risk for back pain without precipitating trauma or known cause.

Psychologic and emotional stress along with job dissatisfaction are more likely the real issues underlying low back pain (LBP). Personal characteristics play a greater factor in the development of chronic LBP. For example, studies show that even when trauma is involved (such as a fall or car accident), chronic LBP is more likely to develop in adults who blame others for the accident.

The study of LBP is a complex, multifactorial problem. Your observations match what many studies have shown all along.

A study of low back pain (LBP) in amateur tennis athletes was done recently in Germany. Tennis athletes with LBP were tested and compared with tennis athletes without back pain.

Both groups did a specific exercise program every day for seven weeks. Everyone was tested again at the end of that time. The results showed that everyone increased in trunk extension strength. However, trunk extension strength wasn’t linked with LBP.

The researchers were surprised to find that handedness was a key factor. Right-handed players with LBP had lower electrical activity in the muscles on the left side of the spine. The same was true for left-handed players (reduced strength on the right side). These changes were still present even after the exercise program.

Other studies have shown that muscle recruitment patterns are changed by training or handedness. With tennis players, one-sided motions may lead to asymmetric (uneven) patterns of muscle activity.

As a result, muscular imbalances occur, which may or may not be linked with LBP. Further study is needed to find out if neuromuscular imbalance is the cause or result of LBP. It’s likely that a specific exercise program to retrain muscular imbalance is possible. Whether or not it will reduce back pain or other injuries is unknown.

There are conflicting results from studies on this subject. Some research shows muscular flexibility is linked with low back pain (LBP). Other studies don’t show a link at all. Likewise, the same results have been reported for strength of the low back muscles and LBP.

In a recent study from Germany, electrical activity of the erector spinae muscle alongside the spine was tested in amateur tennis athletes. Some of the athletes had LBP. Others did not. The researchers did not find a correlation between spinal mobility and muscular flexibility with LBP.

When analyzing the data individually (instead of together), erector spinae flexibility had a significant relationship to LBP. When combined with spinal mobility, this effect was not significant.

It’s likely that a neuromuscular imbalance is the real problem. When the muscles don’t contract at the right time (too soon, too late) or they are activated with too little power, an imbalance occurs. This imbalance is the subject of many new studies as scientists continue trying to find the cause of LBP.

Until we know more, a general program of conditioning, strengthening, and stretching is advised for overall fitness and prevention of back pain.

Total disc replacement or total disc arthroplasty (TDA) is a fairly new treatment option for chronic back pain. As with any new type of surgery (especially one involving an implant) patient selection is limited.

For now, patients must be young (18 to 60 years old). There must be a good effort toward conservative (nonoperative) care. This may include antiinflammatory drugs and pain relievers. Physical therapy for pain control and an exercise program is advised before undergoing surgery. Behavioral therapy to address any social or psychologic issues is also important.

MRI scans should show evidence of pressure on the spinal cord or spinal nerves. Usually the patient’s pain and other symptoms are consistent with a disc protrusion or degenerative disc disease.

There are also reasons why patients might not be included. For example, severe osteoporosis or other bone disease may put the patient at too great a risk for fracture and failure.

Orthopedic bone conditions such as scoliosis and stenosis make the patient an unlikely candidate. Pregnancy, obesity, and previous back surgery are other reasons a surgeon may not perform a disc replacement operation.

Your best bet is to see an orthopedic surgeon who performs this operation. After an examination and evaluation, the surgeon can tell you whether or not you are a good candidate for this type of treatment. If not, then alternative options can be discussed.

Back pain and its cause is one of the most difficult problems doctors face. The exact cause of low back pain can be impossible to tell. Even with all our advanced imaging technology, specific pain generators just don’t show up.

Scientists who study this problem suspect the cause of pain is multifactorial. This means there isn’t a single cause but rather, many factors contributing to back pain.

There may be specific anatomical reasons. Social and psychologic variables are often part of the picture. Pain generators from anywhere in the spine can be activated when there is an uneven load, instability, or degeneration from the aging process.

Biologic research has shown that degenerative disc disease can irritate pain fibers within the disc itself. In other words, the disc sets itself up for a painful response to its own demise.

And patients who have had a spinal fusion can still have pain, so there’s some thinking that the source of the pain isn’t even in the spine. Research is ongoing to help answer some of these questions — and especially to identify the source of back pain. You aren’t alone in wondering what’s going on.

Low back pain is a major problem for employers — especially where the job involves physical activity or lifting. Studies show that about one out of every four workers is unable to return to his or her previous work level. Sometimes they don’t return to work at all.

Researchers in the Netherlands have been studying this problem. They have found three things that keep workers out of work:

Odds ratios for workers’ comp (WC) patients with back pain are extremely difficult to predict. Studies show varying results. There is a general trend toward poor results after spinal fusion for WC patients.

In a preliminary study from Ohio, out of 725 WC patients who had lumbar fusion, only six per cent were back on the job after a full year. Almost one-third of the group ended up having a second operation. And the use of narcotics for pain control was very high (90 per cent).

Doctors aren’t sure what is the problem. Perhaps it’s just part of the WC dilemma. Or maybe there’s something about the surgery itself that leads to such a poor result. Social, psychologic, and behavioral factors can’t be ignored.

Smaller studies report disability rates as high as 25 per cent after a single-level fusion. Disability rates went up for WC patients having two- or three-level fusions. There was 100 per cent disability reported for the group having a three-level fusion.

It’s possible that results improve over time. Longer studies are needed to report the results of spinal fusion after two, five, and 10 years. Your motivation to get back to the job may also be a positive factor in your own case.

You’ve come upon a major dilemma when it comes to health care, technology, and costs. There are many experts who don’t advocate the use of treatment just because it’s available. The rising costs of health care make it necessary to find out who can benefit most from each type of treatment.

The artificial disc replacements (ADRs) are new enough that we still don’t know for sure who can benefit most. There may be some patients who truly would do better with a lumbar fusion instead of an ADR. The opposite may be equally true.

Third party payers (insurance companies, Medicare) want to know that ADRs have been proven superior to other treatments known to be effective. How reliable is the data collected on results if the companies who designed the new ADRs do all the research?

There are many questions that remain to be answered before insurance companies can or will approve the use of ADRs in patients with disc problems. How long will the implant last? Will patients end up having a spinal fusion anyway if the ADR fails?

Will patients gain more function and/or have less pain with an ADR compared with spinal fusion? If the ADRs are approved but a patient still wants a fusion, will it be covered? Many more studies must be done to provide reliable and valid results before these questions will be finally answered.

From studies done over the last 15 years, it seems that the results of lumbar fusion for chronic back pain could be better. In 1994, disabled workers in the state of Washington were studied. All had spinal fusion and high rates of disability afterwards. Continued back pain led to a second operation for many of the workers.

There’s a current, ongoing study in Ohio with similar results. Researchers are hoping with access to the entire Ohio WC database, they can take a closer look at who gets better and who doesn’t. How do patients with disc problems compare to patients with arthritic conditions? Or any other type of back problem?

Everyone will be followed for at least two years. Results will be measured by how many get back to work and how many end up on disability. Other outcomes will include how much and what kind of pain medications are used before and after surgery. We will continue to report the results as they are published.